Can Treating Your Upper Back Improve Shoulder Pain? What Research Reveals
Key insights: 60-second read
- Thoracic manual therapy may help shoulder pain and disability - but the effectiveness depends on the specific technique used. Maitland mobilisation shows the most promise.
- Maitland mobilisation reduced pain and disability in subacromial impingement syndrome - with moderate certainty evidence, achieving clinically meaningful improvements.
- High-velocity low-amplitude thrust (cracking) did not show significant benefit - when compared to sham treatment for pain or disability in shoulder dysfunction.
- Thoracic manual therapy improved shoulder range of motion - pooled results showed significant improvements in flexion, abduction, internal rotation, and external rotation.
- Evidence for adhesive capsulitis remains limited - the current research is insufficient to make definitive recommendations for this population.
Shoulder pain is the third most common musculoskeletal disorder, affecting up to 16% of the general population. Approximately 40% of those affected experience symptoms lasting more than 12 months, often with recurrent episodes and limitations in daily activities.
The thoracic spine - your upper and mid back - plays a key role in supporting shoulder movement and load distribution.
A systematic review and meta-analysis published in Musculoskeletal Science and Practice has examined whether thoracic manual therapy can help improve shoulder pain and which type of manual therapy was best.
So, let's dive into what they found.
On this page
The Study: Methods and Participants
This was a systematic review and meta-analysis of randomised controlled trials.
Study Details
- Participants: 12 randomised controlled trials involving 508 participants were included. All subjects were aged between 30 and 65 years (mean age 44.5 years).
- Conditions: Most studies focused on subacromial impingement syndrome or rotator cuff injury (9 studies), with two studies on adhesive capsulitis and one study not reporting pathology.
- Interventions: Seven studies used high-velocity low-amplitude thrust (commonly known as "cracking"), three used Maitland mobilisation, one used Mulligan sustained natural apophyseal glides, and one did not specify the technique.
- Outcomes: Pain was assessed using the Numeric Pain Rating Scale or Visual Analogue Scale. Disability was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire or the Shoulder Pain and Disability Index.
Five studies compared thoracic manual therapy as an adjunct to other physiotherapy treatments such as exercise and hot packs. Five studies compared thoracic manual therapy with sham treatment; two studies compared Maitland mobilisation with inactive physical modalities.
What the Results Show
Pain
For subacromial impingement syndrome, the results varied by technique:
- High-velocity low-amplitude thrust: No significant pain relief compared to sham treatment. Very low evidence that "cracking" joints was worthwhile.
- Maitland mobilisation: Significantly reduced pain compared to inactive physical modalities. Moderate-grade evidence.
- Mulligan technique: Showed a significant adjunctive effect when combined with physiotherapy. Low-grade evidence from a single trial.
For adhesive capsulitis, low-grade evidence from one study suggested cracking reduced pain compared to sham.
Disability
For subacromial impingement syndrome:
- High-velocity low-amplitude thrust: Did not significantly reduce disability. Very low-grade evidence.
- Maitland mobilisation: Significantly reduced disability compared to inactive physical modalities. Moderate-grade evidence.
- As an adjunct to physiotherapy: Both Maitland mobilisation and Mulligan technique showed superior disability reduction. Low-grade evidence.
For adhesive capsulitis, very low-grade evidence suggested thoracic manual therapy did not significantly reduce disability.
Range of Motion
Pooled results showed significant improvements in shoulder range of motion for subacromial impingement syndrome:
- Flexion: Mean difference 6.27 degrees
- Abduction: Mean difference 6.72 degrees
- Internal rotation: Mean difference 8.76 degrees
- External rotation: Mean difference 5.92 degrees
Key Finding: The effects of thoracic manual therapy for shoulder dysfunction are technique-specific. Moderate certainty evidence supports Maitland mobilisation for reducing pain and disability in subacromial impingement syndrome, while evidence for high-velocity low-amplitude thrust and Mulligan technique remains limited or inconclusive.
Clinical Perspective: Why the Upper Back Matters
As a physiotherapist who treats shoulder pain every day, these findings align with what I see clinically. Thoracic joint mobilisations are highly effective at improving thoracic mobility and therefore tend to have a strong impact on shoulder pain and function. And this makes sense when we consider that the upper back and shoulder blade are the platform from which all shoulder function is derived.
Think of it this way: your shoulder blade sits on top of your rib cage, which is attached to your thoracic spine. If your thoracic spine is stiff and restricted, your shoulder blade can't move normally. And when your shoulder blade can't move normally, your shoulder joint will likely have to compensate. That compensation can open the door for pain, impingement, and dysfunction over time.
"The upper back and shoulder blade are the platform from which all shoulder function is derived. If the platform is stiff and restricted, the shoulder simply cannot function optimally - no matter how much you strengthen or stretch the shoulder itself."
In my clinical experience, Maitland mobilisation - the technique that showed the most promise in this review - is particularly effective because it uses gentle, graded oscillations to restore accessory joint motion. It's a controlled, respectful way to attempt to free up the thoracic spine and ribcage, and restore the base platform your shoulder needs to have permission to function well.
Similarly, I don't typically have much time for "cracking" joints. Yes, it's a cool party trick, and yes, it can make you feel a little nicer to have that built-up pressure released, but it just doesn't seem to improve the function of the area over time...
This also doesn't mean you should ignore the shoulder itself. Strengthening the rotator cuff, improving scapular control, and addressing any glenohumeral restrictions are all important. But if you're not also addressing the thoracic spine, you may be missing a key piece of the puzzle.
And finally, it's important to constantly mention that everything has to happen for a reason. If upper back and ribcage dysfunction are directly involved in the onset and persistence of your shoulder pain, that dysfunction has to be there for a reason. And for most, it's just the legacy of the basic day-to-day postures and shapes you get into the most. Sitting hunched at a desk, looking down at your phone, slouching into a comfy couch at night to watch TV. Correct these, free up those upper back restrictions, and you may be pleasantly surprised with the result.
What This Means for Your Treatment
- If you have shoulder pain, ask your physiotherapist to assess your thoracic spine mobility.
- Thoracic mobilisation - particularly Maitland techniques - can be a valuable addition to your treatment plan.
- Don't neglect your upper back in your home exercise routine. Thoracic mobility exercises can complement hands-on treatment.
- If you've tried shoulder-focused treatment without success, thoracic spine dysfunction may be the missing link.
- Consider trying the ball mobilisation techniques for your upper back - it's the closest thing I've seen to having a therapist mobilise those joints for you.
Limitations of the Research
The authors acknowledge several limitations:
- High risk of bias: Many included studies had a high risk of bias, primarily due to lack of blinding of participants and outcome assessors.
- Limited generalisability: Findings are limited to adults aged 30 to 65. Results may not apply to younger or older populations.
- Heterogeneity in adhesive capsulitis: Two studies on adhesive capsulitis with different interventions were pooled, which may have introduced heterogeneity.
- Small subgroups: Some subgroups contained very few studies, limiting the precision of the findings.
This systematic review and meta-analysis provides valuable insights into the role of thoracic manual therapy for shoulder dysfunction. The key finding is that the effects are technique-specific.
Moderate certainty evidence supports Maitland mobilisation for reducing pain and disability in subacromial impingement syndrome. High-velocity low-amplitude thrust or "cracking" did not show additional benefit over sham treatment. Evidence for the Mulligan technique and for adhesive capsulitis remains limited.
From a clinical perspective, thoracic mobilisation is a valuable tool for improving thoracic mobility and, by extension, shoulder function. The upper back is the platform from which all shoulder function develops. If you have shoulder pain, it's well worth having your thoracic spine assessed, and ultimately working to optimise it long-term.
- Grant
Frequently Asked Questions
What is thoracic manual therapy?
Thoracic manual therapy refers to hands-on techniques applied to the thoracic spine (your upper and mid back). These can include mobilisation (gentle, graded movements), manipulation (high-velocity low-amplitude thrust), and Mulligan techniques (sustained glides combined with active movement).
Which technique is best for shoulder pain?
Based on this review, Maitland mobilisation has the strongest evidence for reducing pain and disability in subacromial impingement syndrome. High-velocity low-amplitude thrust did not show significant benefit over sham treatment. Mulligan technique shows promise, but evidence is limited.
Why does the thoracic spine matter for shoulder pain?
The thoracic spine is the platform from which all shoulder function develops. Your shoulder blade sits on your rib cage, which attaches to your thoracic spine. If the thoracic spine is stiff, the shoulder blade can't move normally, and the shoulder joint has to compensate. This compensation can lead to pain and dysfunction.
Can thoracic manual therapy help with adhesive capsulitis?
The evidence for adhesive capsulitis remains limited and highly heterogeneous. The current research is insufficient to make definitive recommendations. More high-quality studies are needed.
One key insight from this research
"The effects of thoracic manual therapy for shoulder dysfunction are technique-specific, with moderate-certainty evidence supporting Maitland mobilisation, while evidence for other approaches remains limited or inconclusive. The upper back is the platform from which all shoulder function develops."
Reference
Yu, S., Chen, S., Yang, Z., Ma, X., Gou, L., & Yang, L. (2026). The effects of different types of thoracic manual therapy for shoulder dysfunction: a systematic review with meta-analysis. Musculoskeletal Science and Practice, 84. https://www.mskscienceandpractice.com/article/S2468-7812(26)00081-0/fulltext
Need personalised guidance for your shoulder pain?
If you would like help with shoulder pain, thoracic mobility, or any musculoskeletal dysfunction, you can book with Grant either in Port Macquarie or via an online telehealth consultation.
